Straight From the Source: Use Modifier 25 the Right Way With CCI Manual Tips

Fri, Sep 22, 2017


It can be tricky knowing when to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

More specifically it can be tough to determine whether work performed by a provider amounts to a separate E/M (reportable with modifier 25) on the same DOS as another procedure. And the consequences are big. Just ask the eye institute whose modifier 25 use resulted in a $113, 722.10 settlement with the government.

Helpful hint: The National Correct Coding Initiative Policy Manual for Medicare Services (aka CCI manual) offers …

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Why HHS Says It’s Focusing on Disenrollment Data in MA Plan Oversight

Mon, Sep 18, 2017

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Sicker patients seem to be dropping out of some Medicare Advantage (MA) plans, according to a Government Accountability Office (GAO) report from April 2017. Here’s a closer look at the report and the entities involved.

A Brief Look at MAs and Their 17.6 Million Beneficiaries

CMS contracts with private entities to cover Medicare beneficiaries under the MA program, sometimes called Medicare Part C. MA enrollment was at 17.6 million in 2016, nearly a third of all Medicare beneficiaries. MA organization (MAO) plan offerings can change from one year to the next, but contracts are not allowed to use health status to limit coverage. An MAO contract is specific to a plan type, such as an HMO (which usually restricts patients to in-network providers) or …

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Preview What’s New for Path/Lab in CPT® 2018

Thu, Sep 14, 2017


CPT® 2018 news is taking on momentum. Checking out the MPFS 2018 proposed rule offered us a handy preview of new codes coming in CPT® 2018 priced under MPFS. Let’s turn our attention now to what path/lab coders can expect. We’ll focus here on changes where you’ll have more than one new option to choose from. For more complete analysis, check out Pathology/Lab Coding Alert (if this is your specialty, you’ll be glad you did!).

Note: Adjustments may occur to these codes before the code set implementation date of Jan. 1, 2018.

Make Room …

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ICD-10-CM 2018: Focus on Partial and Complete for Intestinal Obstruction Coding Updates

Mon, Sep 11, 2017


Intestinal obstruction coding changes are coming October 1 with ICD-10-CM 2018, meaning you need to be sure your documentation can stand up to new requirements. Here are some tips from General Surgery Coder to help you on your way.

But first: For those of you with patients affected by recent hurricanes, the CDC has posted “ICD-10-CM Coding Advice for Healthcare Encounters in Hurricane Aftermath” on its ICD-10-CM page.

Add Fifth Character to Codes for Intestinal Adhesions With Obstruction

Under ICD-10-CM 2017, you have K56.5 (Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)). The code is complete and reportable with four characters.

ICD-10-CM 2018, however, says four characters are not enough! You’ll need …

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Will You Benefit From These MPFS Quarterly Update Changes?

Fri, Sep 8, 2017


Keeping up with quarterly Medicare Physician Fee Schedule updates can be tough. One reason is that sometimes the changes are implemented on one date and effective in the past. Confused? Examples can help with that. The changes below have an implementation date of Monday, Oct. 2, 2017, as part of the October quarterly MPFS update. But the effective date is Jan. 1, 2017.

Keep in mind: When the effective date is in the past, you can bring changes that benefit you to your payer’s attention to get payment adjustments on claims already submitted. Just be sure to wait until after the implementation date.

20245 Global Split Gets New Look

Code 20245 (Biopsy, bone, open; deep (e.g., humeral …

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Are These ASCQR Resources on Your List?

Tue, Sep 5, 2017


ASC quality reporting

The Ambulatory Surgical Center Quality Reporting (ASCQR) Program affects Medicare reimbursement for ASCs. In short, ASCs have to meet administrative, data collection, and data submission requirements to avoid a payment reduction. Here’s a look at some ASCQR resources recently listed in Outpatient Facility Coding Alert.


The CMS ASCQR page links to the 2012 OPPS/ASC final rule and 2013 IPPS rule, which offer some historical insights into the program, including initial program requirements. You’ll also find a listing of measure by year.

You’ll get an idea of future goals for …

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ICD-10-CM 2018: Succeed at Heart Failure Coding With This New Note Walk-Through

Thu, Aug 31, 2017


heart failure coding

We’re in the home stretch for ICD-10-CM 2018 prep, with about a month to go. We’ve covered the Official Guidelines, but you need to review the new instructions in the code set that come with code revisions, too. Case in point: Let’s take a closer look at the notes you’ll find with the updated diagnosis codes for heart failure (HF).

Size Up Systolic Additions

Inclusion terms: Existing subcategory I50.2- (Systolic (congestive) heart …

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Part 2: What Does the MPFS Proposed Rule Reveal About CPT® 2018?

Tue, Aug 29, 2017


2018 updates

Welcome to Part 2 of our look at what we can expect in CPT® 2018 based on what’s discussed in the Medicare Physician Fee Schedule 2018 Proposed Rule. Be sure to read Part 1 to get the complete picture. These are proposed codes, so of course keep checking back for in-depth updates once we start posting about the finalized 2018 code set.

Nervous System

Two proposed codes (64xxx) will apply to nerve repair with a nerve allograft. The first code is for the first strand, and you’ll report the second code for separate reporting of each additional strand.


Chest X-rays

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Part 1: What Does the MPFS Proposed Rule Reveal About CPT® 2018?

Sun, Aug 27, 2017

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2018 updates

When the Medicare Physician Fee Schedule Proposed Rule comes out, it includes discussions of how to value new codes, and it’s fun to look for insights into the procedure codes that will be coming our way. Let’s take a quick tour of what’s expected for CPT® 2018 based on what’s in the pages of the MPFS proposed rule.

Note: The proposed codes mentioned, such as 32xxx, are placeholder codes like the ones AMA and CMS use to suggest where the code will be in the code set if the code is finalized.


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